A Male with Extreme Subcutaneous Insulin Resistance: A Case Report

Abstract

Introduction Though insulin has no upper limit in dosage, we do not encounter very high dose requirements too often. The reported case is the first in Bangladesh to require more than 1000 international units (IU) of subcutaneous insulin per day. Case presentation A 44-year old male diabetic patient from Bangladesh presented with unusually uncontrolled diabetes mellitus due to extreme insulin resistance. Despite dramatic increase in insulin step by step up to 1110 IU of concomitant short and intermediate acting insulin per day by subcutaneous route, his blood glucose remained over 12 mmol/L persistently, in all the fasting, pre-prandial, postprandial and random samples. He was also treated with several oral hypoglycemic agents including metformin, vildagliptin, glimepiride, pioglitazone and miglitol along with insulin but blood glucose levels remained almost unchanged. However, intravenous infusion of insulin over 4 hours caused a plummet in the glucose level. His blood test for insulin autoantibody was negative. Conclusion This paper provides a scope to review literatures on extreme subcutaneous insulin resistance and its management. It also reveals the limitations of management due to lack of facilities in an underdeveloped country, which hinders proper exploration to many medical issues.

A Case Report of Subcutaneous Insulin Resistance in Type 1 Diabetes, July 2018, Ardabil, Iran

“…Extreme subcutaneous insulin resistance is characterized by severe resistance to subcutaneous insulin with normal or near normal intravenous insulin sensitivity. Established mechanisms of insulin resistance include genetic defects in insulin receptors, insulin receptor antibodies and interference with intracellular insulin action due to the excess of counter-regulatory hormones of inflammatory cytokines and increased insulin clearance [6].…”

“…Insulin resistance is a known cause of hyperglycemia. On a clinical basis, severe insulin resistance is defined as a situation in which a patient requires more than 200 units of insulin daily for more than 2 days [2,6]. Though physicians are familiar with common diseases that are known to be associated with insulin resistance, the majority of us rarely come across a case of extreme insulin resistance.…”

“…Though physicians are familiar with common diseases that are known to be associated with insulin resistance, the majority of us rarely come across a case of extreme insulin resistance. It is usually seen during the attack of diabetic ketoacidosis, although non-ketoacidosis patients can also develop sever insulin resistance [6].…”

A New Optimized Percutaneous Access System for CIPII

“…4 Several treatment approaches have been used to deal with this situation, namely, oral antidiabetic medication, continuous ambulatory intravenous insulin infusion, and last CIPII, which has been proposed to be the best solution for this problem. 4,5 Moreover, recent data suggest it might be helpful to reduce the frequency of hypoglycemic events, and constitutes a last treatment option for those patients unable to reach adequate glycemic control despite standard therapy with multiple insulin injections per day or continuous subcutaneous insulin infusion (CSII). 6,7 Intraperitoneal insulin administration mimics physiology more closely than standard therapies.…”

“…4 Several treatment approaches have been used to deal with this situation, namely, oral antidiabetic medication, continuous ambulatory intravenous insulin infusion, and last CIPII, which has been proposed to be the best solution for this problem. 4,5…”